Government ponders nursing home reform

WASHINGTON (CNN) --The first time Jan Clement found her mother, Esther, neglected in a nursing home she thought it was an aberration, just one bad nursing home.

"I went in and found her shaking uncontrollably, thrashing about, tremendously high fever, totally incoherent," says Clement. "She was diagnosed with pneumonia. No one noticed."

Three nursing homes later, Clement says she now realizes neglect is the norm. She has found her mother lying in her own waste, sitting restrained in a darkened room, ravaged with sores and infections. At one home her mother, left alone in a hallway to eat, choked on a pear and became unconscious. By the time the staff found and revived her, she had brain damage, which worsened her dementia.

Clement says it's not that staff are abusive or callous; they're just overwhelmed.

"There just aren't enough staff to take care of the residents," says Clement, who now has her 98-year-old mother in an assisted care facility she's happy with.

Clement's experience is far from unique. A federal report ordered by Congress during the Clinton administration has found that more than 90 percent of the nation's nursing homes have staffing levels below a minimum acceptable level. For residents that means more bed sores, dehydration, infections, and malnutrition, not to mention the daily indignities like waiting for hours to use the toilet.

In draft recommendations attached to the report, the Bush administration acknowledges "strong and compelling evidence" that staff ratios are linked to quality of care, but argues against imposing federal staffing minimums, saying they would have to be balanced against cost.

In the draft the Bush administration calls for another study on the tradeoff between cost and care and argues in the meantime for a free market approach. Nursing homes would be required to publish staffing information, hoping "staffing levels may simply increase due to the market demand created by an informed public."

The administration declined comment on the recommendations, saying they are only preliminary.

Advocates for the elderly are fed up.

"This is simply unacceptable," says Donna Lenhoff of the National Citizens' Coalition for Nursing Home Reform. She argues the last thing elderly residents need is another study on costs and benefits.

"What's the cost of somebody sitting in their diapers, uncomfortable and miserable, for another hour or two, or three or the whole night?" asks Lenhoff. "What's the cost of somebody sitting unfed or lonely during their meal because there's no aide there who can feed them?"

The report found it would cost the industry $7.6 billion to bring staff -- nurses and nurses' aides -- up to an acceptable level. Most in the industry are opposed to federal staffing mandates.

"Do we need more staff? The answer is yes," says Solange Vivens, who manages a not-for-profit home in Washington D.C. "Is a ratio the way to go? No."

Vivens says rigid ratios would hamstring nursing homes unless they were flexible enough to take into account the wide variety of disabilities that afflict residents. For example, an Alzheimer's patient might need more staff time than a mentally competent resident who can walk with a walker and doesn't need help with eating and going to the bathroom.

Then there's the question of cost. Medicaid pays for the vast majority of nursing home care. Vivens says the rates the government pays are simply too low for homes to get staffing to optimum minimum levels.

"You can't tell me you want to deliver Cadillac care and pay me, you know, for a broken down car. It does not work," she says.

Low pay and the difficulties of working in homes that are understaffed exacerbate the problem. Nursing industry representatives say even if there were ratios, there aren't workers who want the jobs.

Jan Clement thinks it's time the industry, the government and ordinary citizens wake up. After all, she says, we're all going to get old some day.

"If we don't do this, if we don't take care of our frail elderly citizens, each of us has the possibility of finding ourselves sitting in our own waste, sitting unable to walk, sitting restrained, waiting to be fed. Hoping to die."